October 17, 2015

Glycemic Diabetes Management

The American Association of Diabetes Educators has completed their annual meeting. It is not a surprise that most of the topics were about and for those with type 1 diabetes. After the ADA and the joint statement about education for all people with diabetes, I expected more topics for type 2 diabetes, but this did not happen. Yes, they can say that this topic was for all people with diabetes as they did include insulin and about 20 percent of people with type 2 diabetes do use insulin.

While educating hospital staffs about hyperglycemia is important, unless there is education about the use of oral medications, many with type 2 diabetes will continue be left out in the cold and receive little help when hospitalized.

This statement by the speaker Jane Jeffrie Seley, BC-ADM, CDE, CDTC, of New York-Presbyterian/Weill Cornell Medical Center leaves me wondering. “Inpatient glycemic management is best accomplished through interdisciplinary collaboration with physicians, NPs, PAs, RNs, RDs, diabetes educators and pharmacists. Errors can be greatly reduced by implementing system changes that make it easier to do the right thing. One example is auto-calculating the basal insulin dose based on weight and expected sensitivity to insulin instead of requiring prescribers to do the math.”

Best practices for improving inpatient glycemic control have been identified. There are many barriers to implementing them, Seley said. The biggest obstacle to coordinating and implementing successful strategies is the need for ongoing staff education. Successful strategies also involve policy changes, infrastructure adaptations and culture change. None of these will be effective until the hospital administrators and the hospital board of directors adopt them and make this known to those at all levels.

Many institutions across the United States have successfully launched glycemic control programs to improve inpatient insulin safety. One approach that appears to be highly effective is computerized order sets. This approach auto-populates the most recent weight gain into a dosing algorithm that gives a safe yet effective recommendation. This weight-based dosing can significantly reduce insulin dosing errors. Basal and bolus insulins are also listed in separate sections to avoid mixing up insulin types.

Electronic medical record systems (EMRs) such as Sunrise and Epic have the capability to develop comprehensive insulin order sets and decision support tools such as a medical logic memory to remind prescribers to order basal insulin when a patient with type 1 diabetes is switched from prandial insulin to NPO status,” Seley told Endocrinology Advisor.

Currently, many hospitals still do not have comprehensive diabetes management programs in place. By having the AADE emphasize everything for type 1 diabetes patients, those patients with type 2 diabetes will continue to take a back seat in hospital diabetes management.

This means that type 2 diabetes patients will continue to need to champion their own cause and they will need to work harder to get what they need in diabetes management when they are in the hospital.

The other problem facing those with type 2 diabetes will be using insulin when they are in the hospital as most hospitals convert every patient to insulin use when they are an inpatient in the hospital. When it comes to food plans, type 2 patients will need to avoid asking for diabetes menus because the dietitians will overload the meals with carbohydrates instead of serving a meal that could be lower in carbohydrates.

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